All about Paediatric Dengue Fever

1. Dengue Fever
Jasmial Nand
Paediatrics
2014

2. Outline
1. References
2. Introduction
3. Pathogenesis
4. Classification
5. Clinical Course
6. Assessment
7. Investigations
8. Differentials
9. Management
10. Additional Points
11. References

3. 1. References
• Medscape
• Up-to-Date
• WHO Publication
• Dengue Case Management
• CWM ED CME Presentation
• Journal articles
• Tropical Medicine and Int’ Health (2001, 2004)
• Indian Journal of Pediatrics (2006)
• Clinical Microbiology Review (2009)

4. 2. Introduction
• The most common arbovirus globally
• Tropics at risk (approx. 2.5-3 Billion)
• 4 distinct serotypes (1-4)
• Flavivirus (ss RNA)
• Vector-borne (Genus Aedes) but other routes possible
• Common species are aegypti, albopictus and
polynesiensis.
• Transmission/ Outbreak patterns
• Usually self limiting, MR <1%,

5. 3. Pathogenesis
Martina B E E et al.
Clin. Microbiol. Rev.
2009;22:564-581

6. 4. Classification
Infection
Asymptomatic Symptomatic
Undifferentiated Dengue Fever
NO Warning
Signs
Severe Dengue
With Warning
Signs
50-90%

7. 4. Classification (II)
• Dengue fever without warning signs
• Hx of being in endemic area.
• Fever and 2 of the following
• Aches and pains
• Nausea & vomitting
• Rash
• Tourniquet test positive
• Leukopenia

8. 4. Classification (III)
• Dengue with Warning signs
• Fluid accumulation clinically (ascitis, pleural effusion)
• Liver enlargement
• Lethargy (or restlessness)
• Lab (High HCT &/or Low PLT)
• Abdominal pain (or tenderness)
• Vomiting (persistent)
• Insignificant bleeding (Mucosal bleeding)
“Flavi”

9. 4. Classifications (IV)
• Severe Dengue
1. Severe plasma leakage leading to
• Shock
• Fluid accumulation with respiratory distress
2. Severe bleeding as evidenced by a doctor
3. Severe organ involvement
• Liver: AST or ALT >1000
• CNS: Impaired consciousness
• Heart and other organ dysfunctions

10. 5. Clinical Course
• Incubation period (3-7 days)
• Febrile phase (2-7 days)
• Critical phase (1-3 days)
• Marked by defervescence , leukopenia and
thrombocytopenia.
• Recovery phase (or Severe Dengue.)
• May have bradycardia. Important to avoid fluid
overload!
• Patients can and will present in any of the 3 stages so good
history and timeline is critical to know where the patient
stands and what to expect next.

11. 5. Clinical Course (II)
• Severe Dengue
• Recognising shock is important. Case fatality as
high 12%
• Usually on day 4/5 of illness.
• Pulse pressure is <20mmHg
• Poor capillary perfusion
• Cold extremities
• Delayed cap. Refill
• Tachycardia
• Hypotension is often a late sign

12. 6. Assessment
• History
• Important to determine timeline, family history and
past infections in mother for infants.
• N.B. Maternal antibodies only protect for first 6 months.
• Physical Exam
• Vitals must be carefully observed and mental state
• Tourniquet test (>20 petechiae/inch2)
• Usu. Non-specific but maculopapular rash,
conjunctival injection, pharyngeal oedema,
lymphadenopathy and hepatomegaly may be seen in
upto 50% of cases.

13. 7. Investigations
• Serology:
• Within 3 days NS1 Strip test
• > 3days IgM (Potential for false positive present for 6 days
though)
• IgG will indicate secondary infection (A fourfold titre increase is
needed)
• Bloods
• FBC- Leukopenia, Changes in HCT.
• PLT- <150,000
• Peripheral blood smear- Transformed lymphocytes
• Albumin- low due to extravasation
• Liver function tests
• Urine output
• CXR, AXR, USS- to pick up fluid accumulation

14. 8. Differentials
Febrile Stage
• Leptospirosis
• Measles
• Typhoid
• Malaria
Critical Phase
• AFI
• As before
• Surgical
• Acute abdomen
• Upper GI Bleed
Use the timeline to differentiate. And these factors
favour Dengue: High fever, rash, retro-orbital pain
thrombocytopenia, leukopenia, absence of cough, and
absence of sore-throat.

15. 9. Management
Steps to take
1. Diagnosis, and classification of phase and
severity
2. Deciding if to be sent home, inpatient or
emergency referral and treatment.
3. Disease notification

16. 9. Management (II)
• Group A- Outpatient
• No warning signs
• Stable socio-economic status
• Group B- Inpatient
• Warning signs
• Infants
• Poor socio-economic situation
• Malnutrition, concurrent infections
• Group C- Emergency Inpatient
• Severe dengue- Plasma leakage, shock, fluid
accumulation, severe bleeds, organ impairment.

17. 9. Management (III)
Group A
• As doctor/clinic
• ORS, PCT, Bedrest, Vigilance
• Schedule daily followups. Monitor FBC, dehydration,
warning signs and defervescence
• Family advice
• Control fever (PCT 10-15mg/kg Q6H)
• Prevent dehydration
• Prevent spread within household
• Watch for warning signs as temp drops after 3-8 days.

18. 9. Management (IV)
Group B
• Admit. Assess fluid status, FBC and vitals every 4 hours
• Continually monitor for shock and severe dengue
• IV fluids- Crystalloids at 6ml/kg/hr first 2 hours and then
reassess and drop to 2-3ml/kg/hr. Maintain urine output
and perfusion. Usu. Will pass soon into recovery or
severe dengue.
• If HCT and BP stable reduce fluids
• If patient worsens increase to 20ml/kg for 1 hour and
assess.
• If danger signs picked up proceed to Group C
management

19. 9. Management (V)
Group C- Compensated Shock
• Admit to PICU or NICU
• Obtain investigations, assess fluid status and monitor
vitals as per ward protocol
• Fluid: 20ml/kg crystalloid over 1 hour and reduce to
10ml/kg for next hour if responsive and then 2-
3ml/kg/hr for next 6-8 hours.
• If not improving, change to colloid solution 10-15ml/kg
over 1 hour. Revert to crystalloids asap
• Once signs of reabsorbtion seen (bradycardia, rash) taper
fluids down to maintenance levels to prevent
hypervolaemia.

20. 9. Management (VI)
Group C- Hypotensive Shock or Hemorrhagic
• Admit to Nice or PICU, resuscitate as before.
• If after colloids patient still deteriorates (HCT,
etc) transfusion ma be necessary, if HCT drops
sharply.
• 5-10ml whole blood slowly over 2-4 hours and
monitor HCT.
• Avoid IM injections and movement to prevent
further bleeding

21. 9. Management (VII)
Fluid Overload
• Signs
• Resp. distress
• Cyanosis
• Ascitis
• Periorbital or soft tissue oedema
• Treatment
• Inotropic agents may be needed with small colloid
boluses. Avoid diuretics
• Aspirating large effusions
• PPV before pulmonary oedema develops

22. 9. Management (VIII)
Discharge Criteria
• Clinically
• No fever for 48 hours
• Gen. well-being, appetite, hemodynamic status, urine
output all improved and no respiratory distress
• Labs
• Increasing trend of platelets
• Stable HCT without intravenous fluids.

23. 10. Additional Points
• Atypical presentations make for worse prognosis .
• Interestingly, the latest outbreak in Fiji saw a rise in Guillain-
Barre syndrome. Currently under investigation.
• Children with suspected dengue can deteriorate very fast and
a high index of suspicion is needed on our part.
• Plasma leakage is the most specific and life-threatening
feature of severe dengue. Watch for the critical period
carefully (Deferevescence) and don’t overload with fluid.
• Primary prevention is the way out as vaccines are not
approved yet. Commed’s important afterall! 

24. 11. References
• Medscape
• Up-to-Date
• WHO Publication
• Dengue Case Management
• CWM ED CME Presentation
• Journal articles
• Tropical Medicine and Int’ Health (2001, 2004)
• Indian Journal of Pediatrics (2006)
• Clinical Microbiology Review (2009)
The End